Does the Organizational Quality of the Psychiatric Nurse Practice 10.13.08

Nancy P. Hanrahan, PhD, RN, PMHCNS-BC Assistant Professor, University of Pennsylvania School of Nursing; Faculty in the Center for Health Outcomes and Policy Research; Senior Fellow, Leonard Davis Institute for Economics BACKGROUND AND SIGNIFICANCE Organizations play a central role in the effectiveness of nursing practice and the quality of patient care (Institute of Medicine, 2004). A growing body of research shows that nursing practice in medical surgical hospital settings is facilitated or undermined by organizational factors that are generated at the system-level by management decisions (Aiken, Clarke, Sloane et al., 2002; Clarke et al., 2002; Aiken et al., 2003; Lake, 2007; Aiken et al., 2008; Friese et al., 2008). Studies of psychiatric hospital settings point to the importance of organizational factors on safe and effective patient care (Delaney & Johnson, 2006; Bowers et al., 2007; Johnson & Delaney, 2007). However, few studies in the U.S. have empirically measured organizational factors or examined the effect of the quality of the nurse practice environment on outcomes. This study will help to build an evidence base for the relationship between the organization of nurse practice environments and untoward clinical outcomes by using nationally-endorsed measures of multiple domains of the nurse’s practice environment. SAMPLE Pennsylvania registered nurses (RNs) who responded to a 1999 nurse survey about the quality of patient care and their work environments are the sample for this study (Aiken, Clarke, Sloane et al., 2002; Aiken et al., 2003). The survey had an overall response rate of 52%. The study displayed herein included RNs who provided direct patient care as a staff nurse and worked in a medical-surgical or psychiatric setting in a general hospital. The sample was further reduced by selecting only those hospitals with a minimum of 15 RNs to provide enough RNs to obtain a reliable and valid response when aggregated to the hospital level (Lake & Friese, 2006). The final nurse sample for this study was 5,804 RNs (357 PRNs and 5,447 RNs working in 66 hospitals) EXPLANATORY VARIABLES The Practice Environment Scale-Nurse Work Index (PES-NWI) (Lake, 2002) is a measure of organizational factors known to influence the quality of the Nurse Practice Environment (NPE). The instrument has five domains (listed below), a composite score, and a three category scale ranking hospitals as "Favorable, Mixed, and Unfavorable“ nurse practice environments. The PES-NWI uses a Likert scale where 1=disagree, 2=somewhat disagree, 3=somewhat agree, and 4=agree. Reliability coefficients for the five subscales indicated high internal consistency with Cronbach Alpha scores from 0.77 to 0.82. CONTROL VARIABLES Nurse Demographic and Work Characteristics : age, gender, and years of experience as a nurse, years of experience at their hospital, years of experience on their unit, a baccalaureate degree in nursing and full-time or part-time work. Hospital Characteristics. A variable was constructed from the American Hospital Associated 1999 survey to represent hospital size as small-medium sized hospitals (1-250 beds) or large sized hospitals (≥ 251 beds). OUTCOME VARIABLES Outcome variables were obtained from a survey of psychiatric nurse reports of how often each of the following incidents occurred involving staff or patients. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Does the Organizational Quality of the Psychiatric Nurse Practice Environment influence occurrences of wrong medication, nosocomial infections, complaints, work injuries, patient falls, and verbal abuse of nurses in general hospital psychiatric settings? Table 1. Nurse and Hospital Characteristics PRNs N=357 RNs N=5,447 p Value Nurse Characteristics Age, mean (sd) 45.0 (10.5) 39 (9.4) p<0.000 Years as RN, mean (sd) 16.0 (11.1) 13.4 (9.5) p<0.000 Years as an RN, mean (sd) 10.1 (8.6) 10.2 (8.0) p<0.990 Years working on Unit, mean (sd) 6.6 (5.8) 7.1 (6.3) p<0.167 Working full-time (%) 54.40% 61.20% p<0.003 Education: BSN (%) 40.00% 41.60% p<0.442 Male (%) 7.80% 6.20% p<0.241 Hospital Characteristics n % Bed size: Small <100 2.4% Bed size: Medium ≥ 100 <250 35.3% Bed size: Large >250 62.3% Number of Non-Teaching Hospitals 36 67.1% Number of Teaching Hospitals 20 32.9% RNs per hospital, mean (sd) 146 81.0 PRNs per hospital, mean (sd) 6.4 3.3 Note: PRNs=Psychiatric Registered Nurses; RNs=Non-psychiatric Registered Nurses *ttest and pearson's chi squared were used to test for significant differences between the PRNs and the RNs. Table 3.0 Unadjusted and Adjusted Odds Ratios Indicating the Effect of the Quality of the Nurse Practice Environment on Psychiatric Nurse Reports of Occasional or Frequent Untoward Clinical Incidents in Inpatient Psychiatric Settings in General Hospitals Wrong Medication or Dose Nosocomial Infections Patient Falls with Injuries Work-related Injuries to Staff Verbal Abuse Directed Toward RNs Complaints from Patients or Families Patient's Cannot Manage at Discharge Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Unadjusted OR (CI) p value Adjusted OR (CI) p value Composite Score PES-NWI (M=2.61; SD=.15) .22 (0.33-1.44) 0.114 .20 .03-1.30 .087 . 06 .01-.41 0.004 .04 .01-.30 .002 .17 .04-.79 0.025 .15 .03-.73 .019 .23 .05-1.01 .051 .25 .06-1.12 .070 .31 .05-1.87 .201 .29 .05-1.67 .167 .72 .17-3.10 0.658 .62 .13-2.94 .547 1.6 .24-10.7 .625 1.34 .22-8.20 .748 Nurse Participation in Hospital Affairs (M= 2.39; SD =0.23) .49 0.12-2.02 0.327 .49 .12-1.93 .307 .43 .09-1.90 0.263 .34 .07-1.52 .159 .53 .17-1.69 0.226 .50 .15-1.62 .245 .44 .15-1.26 .126 .47 .15-1.32 .146 .55 .17-1.78 .319 .52 .16-1.69 .278 .93 .35-2.45 0.878 .88 .32-2.45 .812 .95 .30-3.02 .934 .76 .25-2.40 .632 Foundations for Quality of Care (M= 2.85; SD =0.16) .28 0.03-2.26 0.231 .28 .04-2.21 .226 .10 .01-.79 0.29 .07 .01-.533 .010 .49 .09-2.57 0.401 .46 .68-1.80 .364 .33 .08-1.30 .114 .35 .08-1.50 .158 .34 .05-2.11 .245 .34 .05-2.16 .252 .82 .18-3.75 0.793 .88 .18-4.40 .873 2.52 .43-14.6 .304 1.90 .36-10.18 .452 Manager Skill, Leadership (M= 2.37 SD =0.23) .38 0.09-1.57 0.180 .32 .08-1.31 .113 .13 .03-.58 .008 .12 .03-.54 .006 .18 .05-.61 .006 .16 .05-.51 .002 .29 .09-.95 .041 .30 .09-1.01 .054 .34 .08-1.53 .161 .34 .08-1.50 .154 .54 .17-1.74 0.301 .48 .13-1.50 .193 .76 .15-3.80 .738 .69 .16-3.01 .624 Nurse-Physician Relationship (M= 2.77 SD =0.16) .23 .03-1.71 0.151 .164 .02-1.2 .074 .03 .01-.12 0.000 .02 .004-.124 .000 .19 .03-1.18 0.08 .16 .10-.51 .002 .44 .11-1.80 .251 .52 .12-2.13 .361 .34 .06-1.90 .218 .29 .05-1.74 .175 .75 .16-3.50 0.712 .54 .11-2.70 .449 4.10 1.8-9.5 .001 3.6 1.65-7.9 .001 Staffing & Resources .44 0.16-1.24 0.121 .44 .15-1.35 .151 .24 .06-.98 0.047 .20 .05-.91 .037 .35 .13-.93 0.036 .36 .14-.95 .039 .46 .17-1.25 .130 .50 .18-1.35 .169 .72 .20-2.60 .614 .69 .21-2.32 .552 1.07 .43-2.69 .886 1.03 .37-2.87 .955 2.01 .60-7.10 .276 1.93 .54-6.93 .315 Note : Odds ratios are from robust logistic regression models adjusted for hospital size), psychiatric nurse characteristics (gender, bachelor's degree in nursing, and years as a registered nurse) and clustered within hospitals. Note: Numbers in bold are significant Significance = p values ≤ 0.05 Table 2.0 Percent of Psychiatric Nurses reporting, how often each of the following incidents occurred involving staff or patients and grouped by the Organizational Quality of the Nurse Practice Environment (n=356 PRNs in 66 Hospitals) Unfavorable NPE PRNs=127 Hosp=32 Mixed NPE PRNs=120 Hosp=18 Favorable NPE PRNs=110 Hosp=16 Percentage overall answering Occasional or Frequent PRNs=356 Hosp=66 1 Comparing Unfavorable with Mixed/Favorable NPE % % % % p value Occasional/ frequent wrong medication or dose to a patient 24.80 15.13 16.83 19.13 0.046 Occasional/ frequent Nosocomial Infections 25.20 17.50 14.00 19.24 0.046 Occasional/ frequent Complaints from patients or their families 64.80 64.17 54.46 61.56 0.350 Occasional/ frequent Patient falls with injuries 40.52 44.17 38.38 44.35 0.169 Occasional/frequent Work-related injuries to staff 47.62 36.67 32.32 39.42 0.008 Occasional/frequent Incidents of verbal abuse directed toward RNs 85.60 73.95 76.77 79.01 0.000 Occasional/ frequent Patient's cannot manage at discharge 16.94 11.86 24.00 17.25 0.000 Note: NPE= Nurse Practice Environment; PRN= Psychiatric Registered Nurse 1 Likelihood Ratio Chi Square Statistic was used to test the goodness of fit for simultaneous analysis of associations in the multiple-classification of the Unfavorable, Mixed, and Favorable Quality Organization of Nurse Practice Environments.

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Does the Organizational Quality of the Psychiatric Nurse Practice 10.13.08